Birgit Ross Hospital Hygiene University Hospital Essen Essen, Germany Should we screen for multiresistant gramnegative Bacteria?
CONCLUSIONS: A program of universal surveillance, contact precautions, hand hygiene, and institutional culture change was associated with a decrease in health careassociated transmissions of and infections with MRSA in a large health care system
Multidrug-resistant Klebsiella pneumoniae Isolates in Participating Countries in 2013 (Resistant to Third-generation Cephalosporins, Fluoroquinolones and Aminoglycosides) This report has been generated from data submitted to TESSy, The European Surveillance System on 2015-06-16. Page: 1 of 1. The report reflects the state of submissions in TESSy as of 2015-06-16 at 09:30
Proportion of Carbapenems Resistant (R+I) Klebsiella pneumoniae Isolates in Participating Countries in 2013 This report has been generated from data submitted to TESSy, The European Surveillance System on 2015-06-16. Page: 1 of 1. The report reflects the state of submissions in TESSy as of 2015-06-16 at 10:01
International dissemination of New Delhi metallo-β-lactamase (NDM) producing Enterobacteriaceae Figure 2. International dissemination of New Delhi metallo-β-lactamase (NDM) producing Enterobacteriaceae. This map indicates countries where NDMproducing Enterobacteriaceae have been described in published reports available as of 11 February, 2011. Because of lack of systematic surveillance for these organisms, countries not highlighted in this figure might also have unreported NDM-producing Enterobacteriaceae. Online ISSN 1537-6591 - Print ISSN 1058-4838 Copyright 2015 Infectious Diseases Society of America
23. März 2015
The specific situation in Germany.
Germany 16 federal states. States have many duties in healthcare, e.g. legislation. Thank you to Walter Popp for the next slides
Infection protection act (2011) 23 Nosocomial infections Commission for hospital hygiene and infection prevention (KRINKO) at Robert Koch Institute (RKI) Develops recommendations to prevent nosocomial infections Ongoing update mandatory
Infection protection act (2011) 23 Nosocomial infections Heads of hospitals are in charge of hospital hygiene working according to scientific knowledge Recommendations of KRINKO and ART have to be implemented New! Example: Recommendation re staff structure from 2009 If not > lack of organisation > legal consequences Statistics about nosocomial infections and multiresistant bacteria Also conclusions, consequences and training of staff about new regulations
A special German way in the classification of gram-negative pathogens
MRGN particularly Enterobacteriaceae E. coli, Klebsiella spp., E. cloacae, Serratia marcescens, Citrobacter spp. außerdem Pseudomonas aeruginosa, Acinetobacter baumanii Epi Bull 36/2011
Pathogen/Resistance Mortality increased? Yes Yes Yes Yes NO Yes No Data available No Data available Yes Yes No Data available Yes
Pathogen/Resistance Standard precautions vs. isolation? Isolation in risk areas Isolation in all areas of the hospital Isolation in risk areas Isolation in all areas of the hospital NO Isolation in all areas of the hospital NO Isolation in all areas of the hospital Isolation in risk areas Isolation in all areas of the hospital Isolation in risk areas Isolation in all areas of the hospital
German Recommendations for Screening and Isolation of Gramnegatives MDRO KRINKO 2012
http://www.labor-limbach.de/mrgn-multiresisten.655.0.html
When to screen and how to screen. Screening at hospital admission.patients at risk for 4MRGN Risk Factors in Germany: Previous hospitalisation in foreign countries previous contact with patients with known with 4MRGN (e.g. stay in the same room) previous hospitalization in a German risk area (new!!) Epi Bull 19/2013 Epi Bull 21/2014
When to screen and how to screen. repeated testing could be useful
When to screen and how to screen. Enterobacteriaceae Rectal swabs, where applicable: wounds, urine Pseudomonas aeruginosa: Rectal swabs, throat swabs Acinetobacter baumanii: Throat swabs, skin swabs (inguinal!)
The German experience.
Outbreak due to a Klebsiella pneumoniae strain harbouring KPC-2 and VIM-1 in a German university hospital, July 2010 to January 2011 J Steinmann () 1, M Kaase 2, S Gatermann 2, W Popp 3, E Steinmann 4, M Damman 5, A Paul 5, F Saner 5, J Buer 1, P M Rath 1 Eurosurveillance, Volume 16, Issue 33, 18 August 2011
Outbreak due to a Klebsiella pneumoniae strain harbouring KPC-2 and VIM-1 in a German university hospital, July 2010 to January 2011 J Steinmann () 1, M Kaase 2, S Gatermann 2, W Popp 3, E Steinmann 4, M Damman 5, A Paul 5, F Saner 5, J Buer 1, P M Rath 1 Eurosurveillance, Volume 16, Issue 33, 18 August 2011
Percent of subjects Mortality associated with carbapenem resistant (CR) vs susceptible (CS) Klebsiella pneumoniae (KP) 60 50 40 p<0.001 p<0.001 CRKP CSKP 30 20 10 0 Overall Mortality Attributable Mortality OR 3.71 (1.97-7.01) OR 4.5 (2.16-9.35) Patel G et al. Infect Control Hosp Epidemiol 2008;29:1099-1106
Screening Strategies in Leipzig - Patients with history of CPE - Patients with contact to known CPE pos. patients - Patients with a history of previous medical treatment in countries with high prevalence of CPE - Admission on ICU - Admission on Transplantion Unit (Stem cell or solid organ) - Hospital Stay > 14 days led to repetetive screening - Patients undergoing dialysis
Lübbert, Christoph; Lippmann, Norman; Rodloff, Arne C. Hochresistente Enterobakterien: Systematisches Screening ist notwendig Dtsch Arztebl 2013; 110(46): A-2206 / B-1938 / C-1881
Fig 1 Euler diagram of admissions that have a positive (+) methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction hospital admission nares screen, have a history of a clinical multidrug-resistant organism (MDR... Makoto Jones, Christopher Nielson, Kalpana Gupta, Karim Khader, Martin Evans Collateral benefit of screening patients for methicillin-resistant Staphylococcus aureus at hospital admission: Isolation of patients with multidrug-resistant gram-negative bacteria American Journal of Infection Control, Volume 43, Issue 1, 2015, 31-34 http://dx.doi.org/10.1016/j.ajic.2014.09.016
Unsolved problems in screening for gramnegatives. Screening in Neonatology 2MRGN Since Ciprofloxacin can not be used in (preterm) babies, the pathogens are considered independent of their Resistance to Ciprofloxacin Screening recommendations for gramnegatives: http://www.rki.de/de/content/infekt/epidbull/archiv/2013/ausgaben/42_13.pdf? blob=publicationfile
Unsolved problems in screening for gramnegatives. Screening in Neonatology 2MRGN Since Ciprofloxacin can not be used in (preterm) babies, the pathogens are considered independent of their Resistance to Ciprofloxacin Screening recommendations for gramnegatives: http://www.rki.de/de/content/infekt/epidbull/archiv/2013/ausgaben/42_13.pdf? blob=publicationfile
Neonatology Problems and Questions about screening for multidrugresistant gramnegative Bacteria in Germany Patterned progression of bacterial populations in the premature infant gut PNAS vol. 111 no. 34 > Patricio S. La Rosa, 12522 12527, doi: 10.1073/pnas.1409497111 The human microbiome project. Turnbaugh et al. Nature. 2007 Oct 18;449(7164):804-10.
Conclusions: Screening does not solve all problems... But: - Mortality of MDRO-Infections is high - Lack of treatment options requires improvement of Hospital Hygiene - Screening is essential to identify the patients who need to be isolated - Screening needs consequences
krankenhaushygiene@uk-essen.de Thank you for your attention!